Employer Application For Small Business - Illinois Page 2
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4Group Name_________________________________________________________________________________________________________
# Employees
# Employees
Employer
Employer
Participation
Contribution
Applying for:
Waiving for:
%
% for Dep
# Eligible Employees
Medical
Medical
Medical
# Ineligible Employees
Dental
Dental
Dental
Total # Employees
Vision
Vision
Vision
# Hours per week
Basic Life/AD&D
Basic Life/AD&D
Basic Life/AD&D
to be eligible ________
Dep Life
Dep Life
Dep Life
# Hours per week to be
Supp Life/AD&D
Supp Life/AD&D
Supp Life/AD&D
eligible for Disability
Supp Dep Life/AD&D
Supp Dep Life/AD&D
Supp Dep Life/AD&D
coverage if different
from above ** ________
STD
STD
STD
**For Disability products the
LTD
LTD
LTD
minimum # of work hours per week
.
to be eligible is 30 hours
Other
Other
Other
General Information (continued)
Yes
Subject to ERISA? (Most private sector plans are ERISA plans)
No
If No, please indicate appropriate category:
Church (Additional information needed)
Federal Government
Indian Tribe – Commercial Business
Non-Federal Government (State, Local or Tribal Gov.)
Foreign Government/Foreign Embassy
Non-ERISA Other ________________________________________
Do you continue medical coverage during a leave of absence (not including state continuation or COBRA coverage), and if so, for how
long once an employee begins a leave of absence? (Please refer to the applicable state and federal rules that may require benefits to be
provided for a specific length of time while an employee is on leave.)
Last Day worked (following the last day worked for the minimum hours required to be eligible)
3 Months (following the last day worked for the minimum hours required to be eligible)
6 Months (following the last day worked for the minimum hours required to be eligible)
UnitedHealthcare Policy Special Provisions Related to Medical Eligibility*
No, we do not offer medical coverage during a leave of absence
*UnitedHealthcare Special Provisions Related to Medical Eligibility
If the employer continues to pay required medical premiums and continues participating under the medical policy, the covered person’s
coverage will remain in force for: (1) No longer than 3 consecutive months if the employee is: temporarily laid-off; in part time status; or on an
employer approved leave of absence. (2) No longer than 6 consecutive months if the employee is totally disabled.
If this coverage terminates, the employee may exercise the rights under any applicable Continuation of Medical Coverage provision or the
Conversion of Medical Benefits provision described in the Certificate of Coverage.
Consumer Driven Health Plan Options
Health Savings Account (if selected): Which bank will be used:
OptumBank
Other
Do you currently offer or intend to offer a Health Reimbursement Account (HRA) plan and/or comprehensive supplemental insurance
policy or funding arrangement in addition to this UnitedHealthcare medical plan?
Answers must be accurate whether purchased from UnitedHealthcare or any other insurer or third party administrator.
HRA
Yes
No
If yes, please identify type:
UnitedHealthcare HRA (any HRA design offered through UnitedHealthcare)
Other Administrator HRA
HRA plans administered by other insurers or third party administrators must comply with UnitedHealthcare HRA design standards.
Comprehensive Supplemental Insurance Policy or Funding Arrangement
Yes
No
If you answered "Yes" to either question above, you must choose from the list of UnitedHealthcare HRA-eligible medical plans as shown to you
by your broker or agent. Other plans are not eligible for pairing with these arrangements. Purchase of such arrangements at any point during
the duration of this policy will require you to notify UnitedHealthcare.
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Parent category: Medical